Controversies in Small Vessel Vasculitis - Rheumatology-Nephrology Views
Controversies in Small Vessel Vasculitis - Rheumatology-Nephrology Views
Over the past 20 years, remarkable progress has been made in understanding the pathogenesis and treatment of patients with small vessel vasculitis. Nephrologists and rheumatologists play primary roles in the care of these patients. Whilst there are many areas of agreement between these specialists with respect to understanding and practical care of these patients, there are a number of important areas that differ in the practice patterns of nephrologic and rheumatologic practice. These areas include the nomenclature of these diseases, the role of antineutrophil cytoplasmic antibodies in the pathogenesis, the route and duration of initial cyclophosphamide administration, and, most importantly, the total duration of maintenance therapy following disease remission.
Two experienced clinicians, a rheumatologist and a nephrologist, spar off in support of their opinions.
Patients with small vessel vasculitis (SVV) are cared for by specialists, including rheumatologists, nephrologists and pulmonologists. In some cases, the dominant organ involvement of the disease process dictates patterns of referral. In some regions of the country, the medical community expects the rheumatologist to attend to all aspects of an immune-mediated multisystem disease. In other areas, nephrologists serve in a role similar to the primary care provider. Multispecialty clinics that provide combined nephrology, rheumatology, otolaryngology and pulmonary care specialists deliver the most optimal care. Whilst there are some practice pattern differences as a consequence of referral bias, more commonly, the specific rheumatology or nephrology practice patterns are based on experiential learning or 'legends of yore' rather than hard evidence.
For the purposes of this discussion, we have attempted to flesh out the areas of controversy regarding nephrologic and rheumatologic practices. Both of us have worked in this field for over 20 years and have seen many similar patients; yet, our views and approach on some aspects of nomenclature, diagnosis and management differ.
Over the past 20 years, remarkable progress has been made in understanding the pathogenesis and treatment of patients with small vessel vasculitis. Nephrologists and rheumatologists play primary roles in the care of these patients. Whilst there are many areas of agreement between these specialists with respect to understanding and practical care of these patients, there are a number of important areas that differ in the practice patterns of nephrologic and rheumatologic practice. These areas include the nomenclature of these diseases, the role of antineutrophil cytoplasmic antibodies in the pathogenesis, the route and duration of initial cyclophosphamide administration, and, most importantly, the total duration of maintenance therapy following disease remission.
Two experienced clinicians, a rheumatologist and a nephrologist, spar off in support of their opinions.
Patients with small vessel vasculitis (SVV) are cared for by specialists, including rheumatologists, nephrologists and pulmonologists. In some cases, the dominant organ involvement of the disease process dictates patterns of referral. In some regions of the country, the medical community expects the rheumatologist to attend to all aspects of an immune-mediated multisystem disease. In other areas, nephrologists serve in a role similar to the primary care provider. Multispecialty clinics that provide combined nephrology, rheumatology, otolaryngology and pulmonary care specialists deliver the most optimal care. Whilst there are some practice pattern differences as a consequence of referral bias, more commonly, the specific rheumatology or nephrology practice patterns are based on experiential learning or 'legends of yore' rather than hard evidence.
For the purposes of this discussion, we have attempted to flesh out the areas of controversy regarding nephrologic and rheumatologic practices. Both of us have worked in this field for over 20 years and have seen many similar patients; yet, our views and approach on some aspects of nomenclature, diagnosis and management differ.
